Provider Demographics
NPI:1154322147
Name:DESHPANDE, NISHA (PA)
Entity Type:Individual
Prefix:
First Name:NISHA
Middle Name:
Last Name:DESHPANDE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-3843
Mailing Address - Country:US
Mailing Address - Phone:847-608-1344
Mailing Address - Fax:847-608-0672
Practice Address - Street 1:370 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-3843
Practice Address - Country:US
Practice Address - Phone:847-608-1344
Practice Address - Fax:847-608-0672
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1046425363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP30626Medicare UPIN
IL141941Medicare ID - Type Unspecified